Dangers of Addiction and Pregnancy

Pregnancy can be a time of hope and anticipation; however, this major life transition can also create a lot of stress in women and their loved ones. Physical discomfort, emotional strain, and financial difficulties can cause anxiety and increase the risk of substance abuse in pregnant women or teens. Drug and alcohol abuse are more common during pregnancy than the general public may realize, yet because of the social stigma of prenatal substance abuse and the potential for legal complications, many women are reluctant to seek help. Finding specialized recovery programs that provide safe, supportive, and confidential treatment for pregnant females and their unborn infants is a top priority.

A consideration of the rates of substance abuse among women, and as compared to men, can provide insight into the general level of risk based on one’s sex status. By extension, the usefulness of this information carries over to the subset of pregnant women, although there are separate statistics on the latter group as well.

Per the results of the 2013 National Survey on Drug Use and Health, the following data opens a window into the prevalence of drug abuse among females versus males:

In the month prior to the survey, in the 12+ age group, current drug use among males was greater than among females (11.5 percent versus 7.3 percent).

In terms of initiation into drug use, based on a 12-month survey review, 58.3 percent of the group of individuals who newly used drugs were female.

Regarding alcohol consumption, in the 12+ age group, the percentage of males and females who were current drinkers was similar (57.1 percent versus 47.5 percent).

Among Americans in the 12+ age group, males were more likely than females to drive under the influence (14.1 percent versus 7.9 percent).[1]

With the exception of alcohol use, it appears that males are generally more at risk of drug use (and the attendant risky behaviors like DUI) than females. Of the females who abuse drugs, compared to males, they may have unique needs based on background circumstances. As the National Institute on Drug Abuse discusses, the following are some social factors that are likely to be prevalent among females who use drugs compared to males who engage in drug use:

Lower level of educational attainment (i.e., not having completed high school)

An appreciation for the specific experiences a female may experience prior to or simultaneously with drug abuse can help to inform treatment responses. There is no one-size-fits-all approach to treatment, and research shows that sex and gender are relevant factors. In addition to sex-specific requirements females may have, pregnancy adds another layer of needs that will need to be addressed in treatment.

Pregnancy and Substance Abuse

The informational site Get the Facts provides data on the rates of substance abuse among pregnant females. The most recent data available was averaged over the years 2012-2013 and took into account different age groups as well as trimesters. The data collected reflects the following:

To provide a benchmark, the research noted that 11.4 percent of non-pregnant females, age 15-44, were current users of illicit drugs.

In the 15-44 age group, 5.4 percent of pregnant females were current users of illicit drugs.

When trimesters are considered, in the 15-44 age group of pregnant females, the rate of current illicit drug use was lower in the third trimester compared to the first and second trimesters (2.4 percent, 9 percent, and 4.8 percent respectively).

The age of the pregnant female was found to be a factor in the rate of current illicit drug use..

In the 15-17 age group, 14.6 percent of those who were pregnant were current users of illicit drugs. In the 18-25 group, the rate was 8.6 percent. In the 26-44 age group, the rate dropped to 3.2 percent.[3]

A pregnant female shares a placenta and umbilical cord with the fetus. From a biological standpoint, drugs impact body functions of both the fetus and the mother. The harm that may result from drug abuse depends on different contributing factors, including the type of drugs present, the point in pregnancy during which the drug use commenced, and the frequency of use.

As pregnancy is a unique health condition, the very fact of being with child can cause biological changes that make some drugs more harmful to the mother’s body and the fetus by extension. Further, fetuses have their own unique biological status. A fetus is highly sensitive to drugs and cannot eliminate them with the same proficiency as the mother. As a result, drugs can reach toxic levels in the body of a fetus in addition to causing a host of other health problems.[4]

The Obama Administration and Substance Abuse During Pregnancy

In an effort to curb the rate of babies being born physically dependent on illicit drugs, Tennessee has passed a law making it a misdemeanor criminal offense for females to use drugs during pregnancy. Tennessee hospitals registered 440 cases of infants born drug-dependent from the start of 2014 through June 21 of that year. Other states have since followed suit and passed new laws or construed existing laws to apply to this context. But the Obama Administration disagrees with Tennessee’s prevention strategy.

As the Washington Post reports, the Obama Administration steadfastly supports treatment rather than criminalization in the drug abuse context. As a show of its position, the Obama Administration’s Affordable Care Act expanded healthcare coverage to more fully accommodate treatment and intervention programs. Further, U.S. Attorney General Eric Holder has called for reduced criminal sentences for those who have been convicted of low-level drug offences that may help to stimulate entry into rehab programs. The Obama Administration’s approach helps to destigmatize substance abuse whereas criminalization tends to exacerbate negative perceptions.

Different drugs can have varying types of impact on a fetus. As a general matter, drug use during pregnancy may result in pre-birth or post-birth problems, including miscarriage, still birth, low weight at birth, small birth size, premature delivery, birth defects, sudden infant death syndrome (SIDS), and/or the infant being born with a physical dependency on drugs.

Effects of Drugs on Mother and Baby

During pregnancy, the placenta allows the delivery of oxygen and nutrients from the mother to the fetus through the exchange of blood. Any substance that is carried through the mother’s blood, including alcohol, illegal drugs, or prescription medications, can potentially affect the fetus. Substance abuse may harm the fetus in one or more ways:

By causing complications with pregnancy, such as the separation of the placenta from the uterus or premature contractions of the uterus

By interfering with the delivery of oxygen or vital nutrients through the placenta

By harming the fetus directly by restricting growth or interfering with normal development

By causing spontaneous miscarriage, premature delivery, or fetal death

Even a single episode of drug use during pregnancy can have a negative health outcome for a fetus. Drug abuse also exposes pregnant women to the lifestyle-related risks of drug use, such as communicable diseases, domestic violence, sexual assault, and criminal prosecution. Seeking treatment and stopping drug use (with proper medical advice and supervision) can help at any stage in pregnancy. To provide greater detail on the possible health effects in pregnant women and their unborn babies, consider the following substances of abuse and known side effects:

Alcohol can cause a condition known as fetal alcohol syndrome (FAS), characterized by abnormal facial features, slowed fetal growth, and dysfunctions of the central nervous system (brain and spinal cord). Damage to the central nervous system can lead to a baby growing up to have a low IQ or a behavioral disorder, such as attention deficit hyperactivity disorder (ADHD). Approximately one in every 500-1,000 newborns is born with FAS.

Research shows that 3-16 percent of pregnant females use this drug. According to available studies, after birth, the baby may have poor growth, be at risk for childhood leukemia, and experience neurobehavioral problems, such as irritability, tremors, and/or be prone to high-pitched crying.

Cocaine is a highly addictive central nervous system stimulant that accelerates all of the body’s vital functions. When a pregnant woman uses cocaine, the drug passes directly through the placenta to the fetus, where it has a rapid effect on the developing infant. In utero, there is a risk that the fetus will not survive. Newborns may experience withdrawal symptoms such as irritability, tremors, sleep problems, diarrhea, or seizures. After birth, risks include growth problems, stroke, defects of the limbs, SIDS, and/or abnormal development of the reproductive or urinary system. Children exposed to cocaine in utero have a higher risk of learning disabilities, developmental delays, and low IQ.[5] Although the long-term effects of cocaine exposure in the fetus are not fully understood, research indicates that cocaine has a destructive effect on the heart and central nervous system, and that exposure in utero can increase the risk of serious heart problems later in the individual’s life.[6]

Heroin is a highly addictive opioid narcotic that has no accepted medical use in the United States. Heroin abuse in pregnant women can cause serious complications, including placental abruption (separation of the placenta from the uterine wall), premature labor, and fetal death.[7] In the fetus, heroin can cause restricted growth and low birth weight. If the infant is born physically dependent on this opioid, withdrawal symptoms may occur after birth. Infants with NAS can experience tremors, sweating, poor feeding, diarrhea, vomiting, and seizures. Women who abuse heroin are at risk of respiratory depression, loss of consciousness, and fatal overdose. Intravenous heroin users are also at risk of contracting blood-borne diseases, including hepatitis and HIV/AIDS.

Amphetamines, known commonly as speed, are available through illegal sources or may be abused in the form of certain prescription medications. Amphetamines stimulate the activities of the brain and nerves. In utero, the fetus is at an increased risk of placental separation and death. Exposure to amphetamines in utero has been linked to cleft palate and heart abnormalities.[8] After birth, the infant may experience growth problems.[9]

Methamphetamine, or meth, is a powerful stimulant that directly affects the central nervous system. Prenatal methamphetamine exposure (PME) has been associated with complications with pregnancy, restricted fetal growth, and withdrawal symptoms in newborns. Research shows that PME can cause problems with learning, memory, and judgment later in the child’s life, and that young children exposed to meth in utero may have difficulty with behavioral and emotional control.[10]

Hallucinogenic drugs like LSD, ecstasy, ketamine, peyote, and mushrooms affect the user’s sensory perceptions, level of consciousness, and thought processes. When used during pregnancy, hallucinogenic drugs can increase the risk of miscarriage and premature labor, and they may cause withdrawal symptoms in newborn infants.[11]

Prescription opioids are narcotic medications that are prescribed as pain relievers, cough suppressants, or antidiarrheal medications. Like heroin, which belongs to the same family of opiate-based narcotics, these drugs depress the activity of the central nervous system. Some of the most popular opioids include oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Norco), hydromorphone (Dilaudid), and codeine (Tylenol with Codeine and other combination drugs). These drugs are widely prescribed to pregnant women; however, recent research published in the American Journal of Obstetrics and Gynecology shows that taking opioid analgesics during pregnancy can increase the risk of spina bifida, congenital heart defects, cleft lip and cleft palate.[12] Infants born to women who are addicted to opioid pain relievers are also at risk of opiate withdrawal after birth.

Sedative-hypnotic drugs include prescription sleep aids, tranquilizers, and anti-anxiety medications that calm the central nervous system and induce relaxation or drowsiness. This category of drugs includes benzodiazepines like lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium), which are some of the most widely prescribed drugs in the US, as well as sleeping medications like zolpidem (Ambien) and barbiturates like pentobarbital (Nembutal). Many of the medications in this family of drugs are habit-forming and can cause withdrawal symptoms in the newborn. Infants born to mothers addicted to sedatives show signs of withdrawal syndrome and may have developmental complications or behavioral problems later in childhood.

Because many illicit drugs of abuse and prescription drugs cross the placenta easily, infants born to addicted mothers are often dependent on these substances and must go through a period of withdrawal after birth. This condition is known as neonatal abstinence syndrome (NAS). As the March of Dimes explains, the main drugs involved in NAS are heroin, prescription pain relievers, benzodiazepines, and antidepressants.[9] NAS can occur even when the mother has a lawful prescription for pain medication and takes it in accordance with a doctor’s orders; however, the scope of this discussion is limited to substance abuse (which can include abusing a lawful prescription for pain relievers).

In addition to withdrawal symptoms, the infant may be born small and have breathing problems, fever, blotchy skin, diarrhea, feeding troubles, and seizures. The duration of NAS can range from one week to six months. Infants who are born before the 37-week mark may experience more severe NAS symptoms. Treatment for NAS is available and may include weaning the infant off the drug by using a similar but safer drug (typically in the case of maternal narcotic abuse), using an IV to hydrate the infant, and/or feeding with a high-calorie baby formula.[14]

The rise in heroin use and the prescription pill epidemic has trickled down to the youngest of the population— every hour in the US, a baby is born dependent on opioids.

Treatment for Pregnant Women

The 2013 Treatment Episode Data Set (TEDS) shows that in the 15-44 age group of pregnant females, admission rates to substance abuse treatment recovery facilities ranged between 4.4 and 4.8 percent from 2000-2010.

When seeking a treatment facility, a pregnant female’s starting point is to find a treatment center that has experience accommodating this condition in addition to treating substance abuse and addiction issues. Once such a facility has been identified, the next consideration is to learn whether there is an all-female program option. Although research is limited, it appears that all-female treatment is not more effective for females than mixed-sex treatment programs.[15] The more important predictor of success for females in recovery is the comprehensiveness of the services within the rehab program. However, the availability of all-female programs are crucial because some females will only engage treatment in an all-female environment.[16]

The choice of a treatment facility is often community dependent, and may especially be so for pregnant females who need to stay local for family support as well as to maintain ongoing care under an existing OB-GYN doctor. The first step at a rehab center is to go through the intake process to ensure that the center has the appropriate services. Typically, this process will take a host of considerations into account, such as pregnant clients’ physical conditions, psychological states, readiness for abstinence treatment, social factors, current level of drug intoxication or stage of withdrawal, and whether they have supportive families and/or friends outside of the rehab center.

It’s Never Too Late to Make Healthy Changes

Childbirth Connection, a program of the National Partnership for Women and Families, provides extensive information on how females can improve their health during each week or trimester of pregnancy. There are numerous warnings and advisements available that can help to inform prospective mothers about the many dangers associated with tobacco, alcohol, and other drug use. Designed to be a comprehensive resource, Childbirth Connection covers many facets of the pregnancy process, including its physical, emotional, psychological, and financial dimensions.

Intensive Therapy for Substance Abuse

Typically, after the medical detox process ends, those in recovery will begin intensive therapy treatment that includes both individual and group sessions. Therapy can occur in either an inpatient or outpatient program. There are different research-based therapies available, including Cognitive Behavioral Therapy, Contingency Management therapy, Motivational Interviewing, and couples and family therapy.[23] Different therapy approaches can be incorporated into treatment or introduced at different times. The therapy approach taken generally depends on the treatment philosophy of the particular rehab center.

Medication for Opioid Addiction

To narrow down to the needs of pregnant females once they are in treatment, it is helpful to lay the discussion out as an inverted triangle — from the most broad approaches that can taken to treat females in general to the methods that have been shown to be effective for this discrete group. The framework of substance abuse can be viewed as having two main pillars: medications [also sometimes called pharmacological interventions or medication-assisted treatment (MAT)] and therapy.[17] Whereas therapy applies to anyone in a rehab facility (and different approaches can be tailored to the needs of pregnant females), medications are typically limited to the treatment of alcohol or opioid abuse. Medications for opioid abuse recovery include methadone, buprenorphine (in trademarked drugs Suboxone and Subutex), and naltrexone.[18]

In the general population of recovering opioid users, an attending physician will discuss the pros and cons of each treatment medication. During an induction window of typically at least a week, generally in the withdrawal phase, the attending physician will determine the dosage required for the recovering client to avoid the undesirable physical and psychological side effects of withdrawal as well as to prevent the onset of drug cravings, which

can trigger to a relapse. After withdrawal, medication may continue to be used to help maintain abstinence. In the context of pregnant females who have been abusing an opioid, treatment medications may be used, but special care must be given to protect the health of the fetus.

A discussion of treatment medications in the context of pregnant females is particularly vital as rates of opioid dependence are high. For example, one university-affiliated drug treatment program for pregnant women in North Carolina reports that 40 percent of its clients are treated for opioid dependence, mainly for abuse of prescription pain relievers.[19]At the national level, research shows that from 2000-2009, the number of pregnant females who use or misuse prescription opioids (such as oxycodone, codeine, and hydrocodone) increased from 1.2 to 5.6 in every 1,000 live births. Further, the rate of NAS in infants rose over this period from 1.2 to 3.4 in every 1,000 live births.[20]

Options in Opioid Replacement Therapy

Recent evidence from clinical studies shows that buprenorphine (Suboxone, Subutex) may be a safer, more effective treatment option for women and their babies than methadone. Approved for use in pregnancy in 2002, buprenorphine is less habit-forming than methadone and less likely to cause withdrawal symptoms in pregnant clients and newborns. A research project comparing the effectiveness of methadone and buprenorphine during pregnancy showed that buprenorphine provides the following advantages:

Buprenorphine causes fewer symptoms of opiate withdrawal in newborns.

Unlike methadone, buprenorphine does not have to be taken in a structured clinical setting under direct medical supervision.

The required dose of buprenorphine is generally lower than methadone.

Infants born to mothers who took buprenorphine required less intensive treatment after birth and shorter hospital stays.[21]

In terms of detoxing pregnant females from opioids, most doctors support that using methadone or buprenorphine is safer than a “cold-turkey” approach, which can increase the risk of miscarriage and other complications. Research and clinical cases show that it is possible for pregnant females who are undergoing a supervised medical detox to be gradually tapered off the opioids during any trimester. After detox, pregnant women may also be placed on these treatment medications as a method of abstinence maintenance.[22] Note, however, that these are general treatment advisements. Each rehab center reviews the needs of pregnant clients on a case-by-case basis.

In the case of females in recovery, research shows that in addition to standard therapy treatment, ancillary services can help with treatment retention and outcomes. Supportive services that can help pregnant and non-pregnant females include:

A childcare arrangement that covers the hours during outpatient treatment or during an inpatient stay

In the case of an outpatient program, transportation to and from the site

Information about the state’s laws on using drugs during pregnancy (to help overcome this barrier to treatment)

Help with housing placement after rehab graduation

Domestic violence counseling (as needed)

The presence of positive female role models

Programming that addresses the unique stressors women experience

Education on how to improve self-worth and personal/social capital, such as through help obtaining a GED, enrolling in/completing college, or job training and placement services[24]

A review of the research available on the treatment of pregnant females experiencing substance abuse makes clear that this is a vulnerable group that requires programming sensitive to their needs from both a biological and social standpoint. Rehab centers that create services geared toward helping pregnant females to overcome barriers to treatment are both attractive and practical. Such programming can improve treatment retention and outcomes for both mother and child.

Resources on Pregnancy and Addiction

Childbirth Connection: Planning Pregnancy: Childbirth Connection is national advocacy group dedicated to improving the quality of life of mothers and children. Its website offers resources, publications, and FAQs on how to plan a healthy, drug-free pregnancy.

March of Dimes Pregnancy: Is It Safe? This national charitable organization offers an extensive collection of online resources and information on prenatal and postpartum care for mothers and babies, including a section on the safety of medications, illicit drugs, and other substances.

Pregnancy and Substance Abuse: Medline Plus: A comprehensive guide to the issues surrounding pregnancy and addiction from the U.S. National Library of Medicine, including a basic overview of the issue, interactive tools, research articles, and resources.

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